Safety and upscaling of remote consulting for long-term conditions in primary health care in Nigeria and Tanzania (REaCH trials): stepped-wedge trials of training, mobile data allowance, and implementation
Authors: Jackie Sturt, Frances Griffiths, Motunrayo Ajisola, Joshua Odunayo Akinyemi, Beatrice Chipwaza, Olufunke Fayehun, Bronwyn Harris, Eme Owoaje, Rebecca Rogers, Senga Pemba, Samuel I Watson, Akinyinka Omigbodun, Jackie Sturt, Akinyinka Omigbodun, Andrew Downie, Beatrice Chipwaza, Jonathan Cave, Eme Owoaje, Eniola Olubukola Cadmus, Emmanuel Adebayo, Rebecca Rogers, Frances Griffiths, Richard Harding, Bronwyn Harris, Albino Kalolo, Motunrayo Ajisola, Helen Muir, Kennedy Nkhoma, Joshua Odunayo Akinyemi, Olufunke Fayehun, Richard Lilford, Samuel I. Watson, Senga Pemba, Sylvester Ndegese, Vincent Kiberu, Titus Mashanya, David Ayobami Adewole, Meleji Losyeku
Journal: The Lancet Global Health (2023)

BackgroundIn-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations.MethodsIn these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313.FindingsOverall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients’ open cohort data were analysed (6377 [72·7%] of 8776 females in Nigeria, and 2235 [68·9%] of 3246 females in Tanzania). The mean age of the participants was 55·3 years (SD 13·9) in Nigeria and 59·2 years (14·2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1·06, 95% CI 0·98 to 1·09; p=0·16); however, remote consultations increased four-fold (4·44, 1·34 to >10; p=0·01). In Tanzania, face-to-face (0·94, 0·61 to 1·67; p=0·99) and remote consulting rates (1·17, 0·56 to 5·57; p=0·39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1·05, 0·60 to 1·14; p=0·23; Tanzania: 0·92, 0·60 to 1·67; p=0·97), investigation rates (Nigeria: 1·06, 0·23 to 2·12; p=0·49; Tanzania: 1·15, 0·35 to 1·64; 0·58) or trustworthiness scores (Nigeria: mean difference 0·05, 95% CI –0·45 to 0·42; p=0·89; Tanzania: 0·07, –0·15 to 0·76; p=0·70).InterpretationREaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage.FundingThe UK Research and Innovation Collective Fund.TranslationsFor the Swahili and Yoruba translations of the abstract see Supplementary Materials section.